1. Additional Definitions
Billed Charges. The customary fee-for-service charges billed by an in-network medical care provider (“Network Provider”) for health care services rendered to persons other than Covered Persons.
Covered Charges. The charges for Covered Services accepted by a Network Provider pursuant to the Network Provider Agreement between such Network Provider and Gravie or Gravie’s subcontractors.
Covered Person. For purposes of this addendum, Covered Person shall have the meaning of the term “Member” set forth in the Administrative Services Agreement between Gravie and the Plan Sponsor.
Covered Service. Any care, service, or supply described in the Plan Document as eligible for payment of reimbursement for the Plan.
Cost Share. The amount a Covered Person is required to pay for Covered Services rendered in accordance with the Plan. Cost Shares include any copayments (flat or variable dollar amounts), coinsurance (a defined percentage of the contract charges for services rendered), or deductibles (amount Covered Persons must pay each year before the Plan will pay for Covered Services).
Network Access Agreement. The agreement between Gravie and HPS PayMedix and/or First Health to provide access to Network Providers for Covered Persons.
Nonparticipating Providers. Health care providers that are not Network Providers.
Other capitalized terms not defined above have the meanings set forth in the Administrative Services Agreement and its Exhibits.
2. Network Services
2.1 Provision of Covered Services. Gravie will arrange for Network Providers to render Covered Services to Covered Persons as their patient load, appointment calendars, scope of practice and facilities permit, without discrimination on the basis of race, religion, gender, sexual orientation, color, national origin, age, health status, public assistance status, the execution or failure to execute an advance directive or on any other basis prohibited by law.
2.2 Provider Network Directory. Gravie will give Plan Sponsor a copy of its Provider network directory and will make a listing of its Network Providers available on the internet. The Provider network may change due to the addition or withdrawal of specific providers. Gravie will update its Network Provider information on the internet on an ongoing basis. The current participation status of a Provider may be verified by calling Gravie’s Customer Service number.
3. Additional Rights and Responsibilities of Gravie and Plan Sponsor
3.1 Member Complaints. Plan Sponsor will promptly forward to Gravie any Covered Person complaints about any and all Network Providers. Gravie will review and process Covered Person complaints in accordance with complaint resolution procedures under the applicable Network Access Agreement.
3.2 Verification of Benefits. Gravie or its subcontractors are responsible for verifying benefits accurately and approving Covered Persons’ eligibility for Covered Services.
3.3 Plan Benefit Differential. Plan Sponsor’s Plan will be designed to encourage Covered Persons to seek Covered Services from Network Providers. Member Cost Shares will be at least ten percent (10%) less when Covered Persons receive Covered Services from Network Providers than if those same services were received from Nonparticipating Providers. Plan Sponsor shall designate Network Providers as in-network providers for in-network benefits at the highest level of in-network benefits under the Plan.
3.4 Payment to Network Providers for Covered Services. Plan Sponsor agrees to exclusively use and retain Gravie and its subcontractors to adjudicate, pay, reimburse and remit payment of claims for Covered Services rendered to Covered Persons, whether in or out of network. Plan Sponsor will not enter into agreements with other Provider networks within the Service Area, or “carve out” portions of the Provider network or any related services with other third-party vendors. Gravie or its subcontractors will instruct Network Providers to send to Gravie all claims for Covered Services rendered to Covered Persons. If Plan Sponsor receives any claims directly from Providers, it will return them to the Network Providers, and not Gravie or its subcontractors. Gravie or its subcontractors will reprice each claim according to applicable agreements with Network Providers (“Network Provider Agreements”) and pay any amounts due Network Providers from Plan Sponsor. Plan Sponsor agrees that Network Providers will be paid at the negotiated rate and will not attempt to negotiate different rates with Network Providers directly or through third party vendors.
Plan Sponsor will not disclose the payment terms of the Network Provider Agreements, including but not limited to the Covered Charges, to any third party without Gravie’s prior written approval, except to a party that acts as a paying agent for Plan Sponsor and that has agreed in writing to maintain the confidentiality of such information, unless as may be otherwise required by applicable law.
3.5 Coordination of Benefits. Regardless of any coordination of benefit provisions in any agreement with a Covered Person or Network Provider, the Covered Charges under this Agreement apply only when Plan Sponsor is the primary payor under coordination of benefit rules.
3.6 Limitation or Termination of Plan Sponsor’s Access to Network Providers. Plan Sponsor’s access to Network Providers will terminate automatically upon termination of Gravie’s agreement with the Provider Network subcontractors or Gravie’s agreement with Plan Sponsor. Additionally, Gravie may terminate Plan Sponsor’s access to Network Providers through this Agreement immediately in the case of failure to pay, effective immediately upon written notice to Plan Sponsor. Gravie will terminate a Plan Sponsor’s access to Network Providers when it has reason to believe that the Plan Sponsor has breached any of its obligations set forth in this Network Access Addendum.
3.7 Right to Subcontract. Gravie may subcontract portions of its obligations under this Network Access Addendum and the Administrative Services Agreement. Gravie’s subcontractors may further subcontract portions of their obligations, all subject to the terms of the Network Access Agreement, including the HIPAA Privacy and Security Rules. Expenses for Provider Network management and related expenses to intermediate entities such as vendors of services for subrogation and recovery, coordination of benefits, data analytics and independent review organizations may be paid as part of the funding for health care claims and expenses. Gravie remains ultimately responsible to Plan Sponsor for the performance of any subcontracted services. Gravie and its subcontractors shall maintain Plan records regarding payment of Claims, denial of Claims, and Claims pended for at least seven (7) years.
3.8 Force Majeure. Any force majeure event described in the Agreement, including (if not specified therein) any health pandemics and similar health outbreaks, shall permit Gravie and its key subcontractors in one or more locations, to the extent such event prevents or interferes with their ability to conduct its normal business with respect to Covered Persons, without first seeking consent from Plan Sponsor, to waive certain provisions of the Plan (such as pre-certifications or prior authorization) as necessary to provide continued delivery of benefits under the Plan.
3.9 Member Notifications. When a Claim for benefits has been denied, Covered Persons may be provided the Notice of Adverse Benefit Determination electronically to the extent permitted by law or the Covered Person’s consent.
3.10 Order of Claims Payment; Failure to Fund. The order of Claim payment submitted under the Plan shall be based on the Claim’s approval date, and the timing of payment of approved Claims shall be as set forth in the Network Provider agreements. Payment of Claims may be delayed as necessary to administer coordination of benefits, subrogation, workers’ compensation, other third-party recoveries, payment errors, incomplete claims, and the like. If Plan Sponsor fails to fund Claims, Plan Sponsor must immediately notify all Covered Persons of the Plan and all health care providers whose claims are pended as a result of the delinquency of funding. Such notification shall be in writing and a copy forwarded to Gravie and Gravie’s subcontractors. In such event Providers may, at their option, apply Billed Charges rather than Covered Charges for their services. Gravie retains the right to provide such notice in addition to Plan Sponsor. Gravie may, at its option, suspend the processing of such Plan Sponsor’s Claims and reasonably assist any health care provider who has not been paid, as appropriate, in collecting payment, or terminate the Agreement.
3.11 Nonparticipating Providers. In determining the allowed amount for services by a Nonparticipating (out-of-network) Provider, the Negotiated Rate shall mean (i) such provider’s actual billed charges or, as applicable, the (ii) usual and customary amount for the geographical area in which the provider is located or services are performed; or (iii) if less, negotiated savings rate or discount, if any, arranged through or by Gravie or its subcontractors and accepted by the out-of-network provider in connection with a Covered Person’s Claim. For most services, in addition to any applicable Cost Shares, Covered Persons must pay the difference between the allowed amount and the Billed Charges from the Nonparticipating Provider except as may be otherwise required by law. This amount can be significant and, unlike Cost Shares, does not apply toward any out-of-pocket maximum specified in the Plan.
Benefits for any covered healthcare services received from a Nonparticipating Provider will usually be paid directly to the Covered Person based on the allowed amounts and subject to the other applicable limitations in the Plan. Gravie shall administer claims from Nonparticipating Providers in a manner consistent with the No Surprises Act of the 2021 Consolidated Appropriations Act.
4. Miscellaneous
4.1 Runout. Gravie or its subcontractors provides a runout period of up to twelve (12) months.
4.2 Conflicting Terms. In the event of a conflict between this Network Access Addendum and other terms and conditions of the Administrative Services Agreement, the terms and conditions of this Network Access Addendum will control.